MEDICARE: SOUTHSIDE FAMILY AND COSMETIC DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0401411798	VA

General Provider Information

NPI Number	:	1295008985
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE FAMILY AND COSMETIC DENTISTRY

Provider Business Mailing Address
First Line	:	3505 BOULEVARD
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-1319
Country	:	US
Telephone Number	:	804-520-5009
Fax Number	:	804-520-0901

Provider Business Practice Location Address
First Line	:	3505 BOULEVARD
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-1319
Country	:	US
Telephone Number	:	804-520-5009
Fax Number	:	804-520-0901

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TONYA ADRENA PARRIS-WILKINS
Credential	:	D.D.S.
Telephone Number	:	804-520-5009

Provider Enumeration Date	:	02/12/2012
Last Update Date	:	02/12/2012

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